Incremental Burden Research Articles

Integrating Nutrition Education into Clinical Practice.

The power of physicians to educate patients about nutrition and provide the tools and motivation needed for patients to adopt healthy eating habits is under-utilized. To unleash that power, practicing physicians need to synthesize the latest in nutrition science, integrate it with the established body of evidence on healthy nutrition, and translate and communicate this knowledge to patients in a practical and effective way. Physicians and patients face similar barriers in discussing and incorporating healthy nutrition practices. Tactics and tools that are simple, effective, affordable, and scalable, can be incorporated in clinical practice, thereby making nutrition counseling feasible with only incremental burden to physicians' time and energy. These tactics include: (1) assessing body mass index at every visit, (2) adding obesity or overweight on the problem list, (3) assessing diet, (4) acknowledging risk, (5) being mindful of language, and (6) writing a prescription. Understanding the psychological aspects of food choices and behavioral change, use of technology, and engaging teams are also important. Group visits to address nutrition-related topics are a novel approach to discuss and taste (literally) healthy eating. Finally, physicians' own health and nutrition are powerful predictors of nutrition education to patients and can be a target of intervention as well.

Quantifying the Economic Burden of Myelodysplastic Syndromes Among Elderly US Patients

Introduction: Myelodysplastic syndromes (MDS) include a diverse group of bone marrow disorders associated with high mortality and morbidity. In individuals with MDS, the bone marrow produces dysfunctional blood cells with about one-third of patients progressing to acute myeloid leukemia (AML). Previous estimates of the economic burden of MDS are highly variable, with the existing clinical literature deficient of detailed economic data and existing economic studies lacking accurate information on MDS diagnostics. To address the issue, this study uses registry-linked claims data from SEER-Medicare to estimate the economic burden of MDS among elderly individuals in the US. Methods: We conducted a retrospective case-control study using SEER-Medicare data from January 1, 2010 to December 31, 2016. The study included two cohorts, both aged ≥66 years: (i) patients diagnosed with MDS between January 1, 2011 and December 31, 2015, and (ii) cancer-free controls from a 5% random sample of Medicare beneficiaries. Patients with MDS were followed from index date, defined as the date of initial MDS diagnosis, to death, study end date, or 24 months post-index, whichever occurred first. A 1-year pre-index lookback period was used to identify comorbidities. Except in the instance of death, all individuals had a minimum of 1-year post-index follow-up. We propensity score-matched MDS cases and controls using demographic factors and comorbidities. After examining standardized differences between the MDS and control groups under various caliper widths and allowed numbers of matches, a caliper width of 0.05 of the standard deviation of the propensity score with 25 matched neighbors with replacement was chosen, as this minimized standardized differences across covariates. We calculated average 30-day cost burden for each matched patient based on costs incurred over the number of days in their individual follow-up period. We then estimated incremental healthcare cost burden for patients with MDS relative to the matched controls, including inpatient, outpatient, and pharmaceutical drug costs. We used a generalized linear model (GLM) with a log link and adjusted for demographics and comorbidities. Results: Of the 18,780 patients diagnosed with MDS during the study period, 9,524 met the inclusion criteria. Prior to matching, the control group of 288,877 cancer-free patients was 40% male with a mean age of 75.8 years (SD=8.3), while the MDS group was 57% male with a mean age of 80.1 years (SD=7.4). In addition, standardized differences between the groups were >0.2 for 50% (8/16) of comorbidities considered. After matching, the number of matched controls fell to 109,075 individuals that were 57% male with a mean age of 80.6 (SD=8.4), and standardized differences were <0.04 for all 16 comorbidities. Unadjusted analyses revealed that, in the first two years following diagnosis, patients with MDS had a $6,599/month total cost, $4,005 of which was MDS-related, compared with $2,122/month for matched controls, a difference of $4,478 in total monthly cost (nominal P<.001). After adjusting for patient characteristics using GLM, estimated monthly cost was $7,400/month for patients with MDS and $2,005/month for controls, a difference of $5,395/month (nominal P<.001). This translates to an estimated two-year cost of $177,601 for patients with MDS compared to $48,125 for cancer-free controls, a difference of $129,476. Approximately 58% of this difference was due to higher medical costs, with the remaining 42% due to higher pharmaceutical costs. Higher inpatient hospitalization costs ($2,319/month for patients with MDS; $851/month for controls; $1,468 cost difference, nominal P<.001) and Part B drug costs ($1,434/month for patients with MDS; $71/month for controls; $1,363 cost difference, nominal P<.001) were key drivers of the incremental cost burden. Conclusion: The economic burden of MDS is higher than that of the cancer-free Medicare population, with an estimated incremental adjusted cost burden of nearly $130,000 in the two years following MDS diagnosis. Medical costs make up the majority of this cost difference. Our results provide an updated estimate of the economic burden of MDS using the most recent data and MDS coding methodology, with detailed estimates of cost by component. Our results fall within the range of estimates of previous studies using SEER-Medicare data. Figure Disclosures Shafrin: Precision Medicine Group: Employment, Equity Ownership. Green:Precision Health Economics: Employment, Other: Employee of Precision Health Economics (PHE). PHE received funding from Breath Therapeutics for this research. . Murphy:Precision Medicine Group: Employment. Everson:Precision Medicine Group: Employment. Dennen:Precision Medicine Group: Employment. Price:Jazz Pharmaceuticals: Employment, Equity Ownership. Batt:Precision Medicine Group: Consultancy.

Estimation of the Economic Burden Associated with Major Surgery Due to Von Willebrand Disease Based on Claims Data from the USA

Background: von Willebrand disease (VWD), a rare, inherited bleeding disorder, is associated with impaired hemostasis resulting from a quantitative or qualitative deficit in von Willebrand factor. Limited information exists on the economic burden associated with major surgeries in this patient population, and real-world data may help determine the impact of these procedures. Aims: To estimate the incremental economic burden associated with major surgeries in patients with VWD compared with patients without VWD who had similar types of surgery. Methods: Accessing data from the Truven US health care database (January 2008 to December 2018), we analyzed data from patients with VWD (based on ≥2 diagnoses from different hospital admissions/physician visits, excluding laboratory and radiology orders) and patients without VWD who had undergone a major surgical procedure. The surgical procedure was defined as a medical claim associated with a major therapeutic operating room procedure (International Classification of Diseases, 9th/10th revision codes) or a major procedure (Current Procedural Terminology code). For patients with VWD, the surgical procedure had to have occurred on or after their first VWD diagnosis. Patients without VWD who had undergone major surgeries were selected from a 1% random sample of the Truven database. Patients from both groups (ie, VWD and non-VWD) were included in the study if they had continuous health care plan enrollment ≥12 months prior to (baseline period) and ≥12 months following (study period) their first major surgery, no diagnosis of acquired coagulation factor deficiency, and not undergone surgery used to reduce bleeding associated with VWD (ie, uterine ablation, nasal ablation, or hysterectomy). Patients with VWD were matched (1:1) with patients without VWD using propensity score matching. Health care resource utilization (HCRU: inpatient [IP] admission, emergency room [ER] visits, and outpatient [OP] visits) and associated costs (pharmacy or medical; adjusted to 2018 US dollars [USD] using the medical component of the Consumer Price Index) were measured over the 12-month study period. Adjusted analyses controlling for age, sex, region, health plan, index year, Charlson Comorbidity Index (CCI), comorbidity profile (anemia, anxiety, depression, fatigue, and obesity), and baseline HCRU were conducted using generalized linear regression models. Results: After propensity score matching, 2972 patients with VWD and 2972 patients without VWD who had ≥1 major surgery were selected for analysis (mean [SD] age, 40.53 [20.56] and 40.94 [20.33] years, respectively; female, 73.3% and 73.6%, respectively). Mean (SD) CCI was 0.66 (1.26) and 0.64 (1.30), respectively; and anemia, anxiety, depression, fatigue, and obesity were present in a similar proportion of each group (7−18% of patients with or without VWD). The most common major surgeries were musculoskeletal or digestive in patients with or without VWD (39.6% and 25.0% vs 37.1% and 23.4%, respectively). Patients with VWD were significantly (P<0.0001) more likely to have an IP admission (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.52−1.92) or ER visit (OR, 1.41; 95% CI, 1.25−1.59) than patients without VWD. They also had significantly (P<0.0001) more frequent IP admissions (incidence rate ratio [IRR], 1.47; 95% CI, 1.35−1.60), ER visits (IRR, 1.44; 95% CI, 1.31−1.59), and OP visits (IRR, 1.16; 95% CI, 1.11−1.21) than patients without VWD. Patients with VWD incurred significantly (P<0.0001) higher total health care costs than patients without VWD ($50,733.89 USD vs $30,154.84 USD). The majority of costs were medical: $41,943.22 USD in patients with VWD and $26,233.83 USD in patients without VWD. Conclusions: In this large retrospective analysis of a US commercial health care database, patients with VWD incurred significantly higher HCRU and associated costs following major surgeries compared with patients without VWD who had similar surgeries. Disclosures Oladapo: Baxalta US Inc., a Takeda company: Employment, Equity Ownership. Wu:Shire US Inc., a Takeda company: Employment, Other: a Takeda stockowner. Lu:Baxalta US Inc., a Takeda company: Employment, Equity Ownership. Farahbakhshian:Shire US Inc., a Takeda company: Employment, Equity Ownership. Ewenstein:Baxalta US Inc., a Takeda company: Employment, Equity Ownership, Other: a Takeda stock owner.

Incremental economic burden associated with exudative age-related macular degeneration: a population-based study

BackgroundThe exudative age-related macular degeneration (AMD) causes considerable healthcare costs for patients and healthcare system, which are expected to grow as the population ages. The objective of this study was to assess the incremental economic burden of exudative AMD by comparing total healthcare costs between the exudative AMD group and non-AMD group to understand economic burden related to exudative AMD.MethodsThis retrospective cohort study used the National Health Insurance Service database including the entire Korean population. Exudative AMD group included individuals with at least one claim for ranibizumab and one claim using the registration code for exudative AMD (V201). Non-AMD group was defined as individuals without any claims regarding the diagnostic code of H35.3 or ranibizumab. The exudative AMD group and non-AMD group were matched using a propensity-score model. Incremental healthcare resource utilization and healthcare costs were measured during a one-year follow-up by employing econometric models: ordinary least squares (OLS) with log transformation and heteroscedastic retransformation; and generalized linear model (GLM) with a log link function and gamma distribution.ResultsA total of 7119 exudative AMD patients were matched to 7119 non-AMD patients. The number of outpatient visits was higher in the exudative AMD group (P-value < 0.0001), while the length of hospitalization was shorter in exudative AMD group (P-value < 0.0001). Exudative AMD patients had total costs 2.13 times (95%CI, 2.08–2.17) greater than non-AMD group using OLS, and total costs 4.06 times (95%CI, 3.82–4.31) greater than non-AMD group using GLM. Annual incremental total costs were estimated as $5519 (OLS) and $3699 (GLM).ConclusionsExudative AMD was associated with significantly increased healthcare costs compared to the non-AMD group. Attention is needed to manage the socioeconomic burden of exudative AMD.

Burden of treatment-resistant depression in Medicare: A retrospective claims database analysis.

BackgroundPrevious studies have assessed the incremental economic burden of treatment-resistant depression (TRD) versus non-treatment-resistant major depressive disorder (i.e., non-TRD MDD) in commercially-insured and Medicaid-insured patients, but none have focused on Medicare-insured patients.ObjectiveTo assess healthcare resource utilization (HRU) and costs of patients with TRD versus non-TRD MDD or without major depressive disorder (MDD; i.e., non-MDD) in a Medicare-insured population.MethodsAdult patients were retrospectively identified from the Chronic Condition Warehouse de-identified 100% Medicare database (01/2010-12/2016). MDD was defined as ≥1 MDD diagnosis and ≥1 claim for an antidepressant. Patients initiated on a third antidepressant following two antidepressant treatment regimens of adequate dose and duration were considered to have TRD. The index date was defined as the date of the first antidepressant claim for the TRD and non-TRD MDD cohorts, and as a randomly imputed date for the non-MDD cohort. Patients with TRD were matched 1:1 to non-TRD MDD patients and randomly selected non-MDD patients based on propensity scores. Analyses were also performed for a subset of patients aged ≥65.ResultsOf 29,543 patients with MDD, 3,225 (10.9%) met the study definition of TRD; 157,611 were included in the non-MDD cohort. Matched patients with TRD and non-TRD MDD were, on average, 58.9 and 59.0 years old, respectively. The TRD cohort had higher per-patient-per-year (PPPY) HRU than the non-TRD MDD (e.g., inpatient visits: incidence rate ratio [IRR] = 1.36) and non-MDD cohorts (e.g., inpatient visits: IRR = 1.84, all P<0.001). The TRD cohort had significantly higher total PPPY healthcare costs than the non-TRD MDD cohort ($25,517 vs. $20,425, adjusted cost difference = $3,385) and non-MDD cohort ($25,517 vs. $14,542, adjusted cost difference = $4,015, all P<0.001). Similar results were found for the subset of patients ≥65.ConclusionAmong Medicare-insured patients, those with TRD had higher HRU and costs compared to those with non-TRD MDD and non-MDD.

The economic burden of hypertriglyceridemia among US adults with diabetes or atherosclerotic cardiovascular disease on statin therapy

Hypertriglyceridemia (HTG) is associated with increased cardiovascular disease (CVD) risk. However, the cost burden of HTG-related CVD in high-risk US adults on statins has not been well characterized. We estimated the HTG-related health care cost burden among US adults with CVD or diabetes taking statin therapy. We estimated population sizes and annual health care costs among US adults aged ≥45years with diabetes or CVD taking statin therapy with normal triglycerides (TGs) defined as TG<150mg/dL compared with those with HTG defined as TG ≥ 150mg/dL. Population sizes were estimated from the 2007-2014 National Health and Nutrition Examination Surveys. Adjusted mean total annual health care costs in 2015 US dollars were estimated using the Optum Research Database. The annual total health care cost burden was estimated by multiplying the population size by the mean annual total incremental health care costs overall and within subgroups. There were 6.2 (95% confidence interval [CI], 5.4 - 7.1) million and 12.0 (95% CI, 11.1- 12.9) million US adults aged ≥45years with diabetes and/or CVD on statin therapy with TG≥150mg/dL and TG<150mg/dL, respectively. The mean adjusted incremental total one-year health care costs in adults with TG≥150mg/dL compared with those with TG<150mg/dL was $1730 (95% CI, $1160 - $2320). This leads to a projected annual incremental cost burden associated with HTG in patients with diabetes or CVD on statins of $10.7 billion (95% CI, $6.8B - $14.6B). In US adults on statins and at high risk for CVD, the health care costs associated with HTG are substantial.

Prevalence and economic burden of comorbid anxiety and depression among patients with moderate-to-severe psoriasis

Objective: To describe the prevalence and costs of anxiety and depression among moderate-to-severe psoriasis (PsO) patients in a commercially-insured US population.Methods: The IBM MarketScan Commercial database was used to select adults with moderate-to-severe PsO (≥1 PsO diagnosis and ≥1 systemic or biologic medication) within each calendar year from 2014 to 2016. Adults with no diagnosis of PsO or similar disorders were randomly selected (2014–2016) and matched 1:1 to PsO patients to compare the prevalence of anxiety and depression each year. Moderate-to-severe PsO patients identified in 2014 with continuous enrollment through 2015 were stratified into those with treated anxiety and/or depression (≥1 anxiety or depression diagnosis plus any anxiolytics, antidepressants, or antipsychotics within 30 days) vs those without anxiety/depression, and then matched 1:1 to determine the incremental burden of treated anxiety/depression among PsO patients. All-cause and PsO-related healthcare costs were compared between the matched cohorts using generalized linear models.Results: In total, 69,644 matched PsO and non-PsO patients were identified in 2014, 61,478 in 2015, and 66,880 in 2016. The prevalence of anxiety/depression among PsO patients increased more than for matched controls, from 18.2% vs 12.2% in 2014 (p < 0.01) to 19.6% vs 13.1% in 2016 (p < 0.01). Prevalence of treated anxiety/depression followed the same trend, with increases from 14.5% vs 8.9% in 2014 (p < 0.01) to 15.9% vs 9.9% in 2016 (p < 0.01). For patients with moderate-to-severe PsO, unadjusted incremental all-cause healthcare costs associated with treated anxiety/depression were $8,077 (p < 0.01); 91% was due to utilization of medical services such as hospitalizations, ER visits, office visits, and other outpatient services (all p < 0.01).Conclusions: The prevalence of psychiatric disorders is higher among PsO patients than the general population, and the incremental burden of treated anxiety/depression is substantial. Further research is needed, but PsO treatments that improve psychiatric symptoms such as anxiety/depression may benefit patients and reduce their economic burden.

External Legal Protection for Capital Investors from Political Risk

Constitution suggests that economic development in Indonesia must involve participation of the society, as reflected by Article 33 Paragraph (4) of the 1945 Constitution of the Republic of Indonesia after amendment. The definition of togetherness as mentioned in Article 33 Paragraph (4) should be viewed from wider perspective. It is essential that people be aware that fund and capacity of the government are still an issue when it is linked to the economic development, given that the development is a complex matter. Therefore, the participation from the society is necessary to help achieve the success in national development. Investment can be considered to support the development, either it is domestic investment or foreign investment. In terms of risk transfer, it surely involves some liabilities embedded to parties transferring the risk based on the agreement to which the transfer is bound. The agreement aimed to regulate the risk transfer is known as insurance agreement. Therefore, it is essential for investors investing their capital to get external protection. The legal theories consisting of legal protection, legal certainty, investment, and insurance were used in this research, while the method was based on normative juridical, supported by statute, conceptual, case, and comparative approaches. The obtained data was analysed with descriptive method where the related phenomena were studied to vividly discover existing condition. The measures taken to assure that the regulations and laws regarding investment and investors, including small and medium enterprises, must be clearly implemented and enforced, transparent, easily accessed and must not give incremental burden. The government needs to consider uncertain policy including predictability and transparency matter, both of which are still taken as the biggest impeding factors in investment. Perspective of investors must also be given to make and revise policy. It is essential that investors understand practical implication of the regulation that regulates the investment regarding what needs to be met and the procedures required in public review and process of appeal in case of disputes.

Physical health burden of PTSD, depression, and their comorbidity in the U.S. veteran population: Morbidity, functioning, and disability

ObjectiveAlthough it is well-established that posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are associated with physical health difficulties among U.S. veterans, the incremental burden of having both disorders relative to either one alone remains largely unknown. The goal of this study was to provide the first population-based characterization of the burden of medical illness associated with PTSD, MDD, and their comorbidity among U.S. veterans. MethodsData were from National Health and Resilience in Veterans Study, a nationally representative survey of U.S. veterans (n = 2732). Analyses (a) examined the magnitude of medical comorbidity and disability associated with PTSD, MDD, and co-occurring PTSD/MDD; and (b) compared physical functioning by PTSD/MDD status. ResultsAfter adjusting for sociodemographic characteristics and substance use disorders, veterans with comorbid PTSD/MDD were more likely to be diagnosed with heart disease, migraine, fibromyalgia, and rheumatoid arthritis compared to those with MDD-only. Conversely, they were at greater odds of being diagnosed with hypercholesterolemia and hypertension relative to those with PTSD-only. Comorbid PTSD/MDD status was associated with approximately three times greater odds of disability compared to MDD alone. Veterans with co-occurring PTSD/MDD and PTSD-only exhibited worse physical functioning than those with MDD-only. ConclusionFindings indicate that veterans with co-occurring PTSD/MDD represent a high-risk group for cardiovascular disease and other health problems, and therefore deserve careful attention from healthcare systems. Further research is needed to investigate mechanisms underlying associations between PTSD/MDD and physical health morbidities, as well as whether treatment of PTSD/MDD can reduce risk for comorbid medical conditions.

Is clinician impression of depression symptom severity associated with incremental economic burden in privately insured US patients with treatment resistant depression?

BackgroundAmong patients with major depressive disorder (MDD), those with treatment-resistant depression (TRD) have a higher economic burden. However, the healthcare resource utilization (HRU) and costs may vary by severity status in TRD patients. This study quantified the incremental economic burden of severity status in TRD patients. MethodsIn a US database of privately insured employees and dependents (07/01/2009–03/31/2015), a claims-based algorithm identified adult TRD patients who were stratified into mild, moderate, and severe cohorts based on the information in the last observed MDD ICD-9-CM code. HRU and costs of moderate and severe cohorts were compared to those of the mild cohort during the 2-year follow-up after the first antidepressant claim. ResultsAmong 6411 TRD patients, 455 (7.1%) were identified as mild, 2153 (33.6%) as moderate, and 1455 (22.7%) as severe. Moderate and severe patients compared to mild had 45% and 150% more inpatient admissions, 65% and 164% more inpatient days, 18% and 54% more emergency department visits and 8% and 10% more outpatient visits per-patient-per-year (PPPY), respectively (all-cause; all p < 0.05). Mean all-cause direct total healthcare costs were $12,123, $16,885, and $18,911 PPPY in mild, moderate, and severe patients, respectively. The all-cause total healthcare cost differences adjusted for baseline characteristics amounted to $3455 in moderate and $5150 in severe versus mild patients, respectively (PPPY; all p < 0.05). LimitationsNot all TRD patients had a severity specifier; the severity specifier was not cross-validated against a depression scale. ConclusionsIncreased severity status is associated with incremental economic burden in TRD patients.

PMH22 IS INCREASED SEVERITY STATUS ASSOCIATED WITH INCREMENTAL ECONOMIC BURDEN IN PRIVATELY INSURED US PATIENTS WITH TREATMENT RESISTANT DEPRESSION?

Among patients with major depressive disorder (MDD), those with treatment-resistant depression (TRD) have a higher economic burden. However, TRD patients are a heterogeneous group, and within it, healthcare resource utilization (HRU) and costs may vary by severity status. This study assessed differences in pharmacotherapy use, HRU and costs in TRD by severity status. A claims-based algorithm identified MDD patients with TRD in a US database of privately insured employees and dependents (OptumHealth Care Solutions, Inc; 07/2009-03/2015). TRD was defined as the initiation of a third antidepressant treatment regimen after two regimens (including augmentation therapy) at adequate dose and duration. TRD patients were stratified into mild, moderate and severe cohorts based on the information in the last observed ICD-9-CM code for MDD. HRU and costs of moderate and severe cohorts were compared to those of the mild control cohort post-index (1st claim for an antidepressant) using regression models adjusted for patient baseline characteristics. Pharmacotherapy use post-index was compared using Chi-square and Wilcoxon rank-sum tests. Among 6,411 patients with TRD, 455 (7.1%) were identified as mild, 2,153 (33.6%) as moderate and 1,455 (22.7%) as severe. Pharmacotherapy use was similar across cohorts. In terms of all-cause HRU, moderate and severe patients compared to mild had 45% and 150% more inpatient admissions, 65% and 164% more inpatient days, 18% and 54% more emergency department visits and 8% and 10% more outpatient visits per-patient-per-year, respectively (all p<0.05). The magnitude of differences among moderate and severe versus mild patients was greater in behavioral-health and depression-related HRU. The incremental all-cause HRU resulted in all-cause total healthcare cost differences of $3,455 in moderate and $5,150 in severe versus mild patients, respectively (per-patient-per-year; all p<0.05). Increased severity status is associated with incremental economic burden in MDD patients with TRD.

CR2 US NATIONAL PAYERS ANALYSIS OF THE INCREMENTAL HEALTHCARE BURDEN AMONG PATIENTS WITH TREATMENT-RESISTANT DEPRESSION

Treatment-resistant depression (TRD) affects an estimated 20-30% of patients with Major Depressive Disorder (MDD) and represents a critical unmet need in the management of the disease. This study compared the healthcare burden of patients with TRD versus non-TRD MDD covered by Commercial, Medicaid, and Medicare health plans. This retrospective longitudinal study used Truven Health Analytics’ Commercial (2006-2016), Medicaid (2007-2015), and Medicare Supplemental (2006-2016) claims databases. Each sample included adults (age ≥18) with MDD, who had received ≥1 antidepressant treatment. Patients with TRD were defined as those who failed ≥2 antidepressants of adequate dose and duration. Within each sample, 15% of the remaining patients were randomly selected to represent the patients with non-TRD MDD. Annual healthcare utilization (hospitalization, outpatient and emergency department/ED visits) and costs were compared across patients with TRD and non-TRD MDD in each of the three cohorts. Logistic, linear, or negative binomial regressions were used to estimate the incremental burden of TRD during the 12-month period immediately following the date of antidepressant treatment initiation (index date), adjusted for demographic and baseline characteristics assessed during 6-month pre-index period. A total of 27,595, 5,556, and 1,856 patients with TRD and 83,949, 18,480, and 7,033 non-TRD MDD in Commercial, Medicaid, and Medicare health plans were analyzed, respectively. TRD was associated with higher healthcare utilization and costs versus non-TRD MDD in all three samples assessed. Patients with TRD had 32%-76% more odds of hospitalization, 38%-45% more odds of ED visits, and 1.29-1.54 times higher rates of outpatient visits compared to non-TRD MDD across all three databases (all p<0.0001). Further, patients with TRD incurred approximately $4,093-$8,054 higher annual treatment costs compared to non-TRD MDD (p<0.0001). Patients with TRD consistently incur higher healthcare burden across health plans. These findings highlight the need for more effective treatments to manage TRD burden.

PDB20 THE IMPACT OF ANXIETY AND DEPRESSION IN TYPE 1 DIABETES MELLITUS (T1DM) PATIENTS WHO EXPERIENCE SEVERE HYPOGLYCEMIC EPISODES (HYPOS)

Severe hypos can be debilitating for patients and can be associated with anxiety and/or depression [A+/-D]. The objective of this analysis is to consider the incremental impact of A+/-D in patients who experience severe hypos. Data were drawn from 2016 Adelphi Disease Specific Programme, a real-world, cross-sectional study in 5EU/USA. Physicians completed forms for the next 2 T1DM patients capturing comorbidities (including anxiety, depression), demographics, disease duration, hypo severity [mild: self-managed, severe: requiring non-medical or medical help], resource utilization. Patients self-reported work, activity impairment, lifestyle impact. To assess differences OLS regressions were conducted for continuous outcomes and logit models for binary outcomes. Regressions accounted for confounding variables: gender, disease duration, BMI. The independent variable was no physician-reported A+/-D vs. A+/-D. Of 1662 patients, 861 (51.8%) never experienced hypos, 637 (38.3%) mild and 164 (9.9%) severe. Of those patients with severe hypos, 27 (16.5%) had A+/-D. Diagnosis of A+/-D was associated with increased time missed from work, (+30.21%, n=37, p<0.001), no difference was observed in productivity while at work. These patients had 2.29 more physician consultations than those without A+/-D (n=131, p=0.031). They also had a greater need for caregiver involvement, although not statistically significant (n=130, p=0.051). Regarding lifestyle, these patients were more likely to be in the sometimes/greatly affected category for appearance/self-confidence issues (OR coefficient:13.54, base=1, n=80, p=0.002), although factors such as freedom to eat/drink, take long journeys, feelings about the future, impact on leisure activities were similar. This study demonstrated there is significant incremental burden of anxiety and depression in T1DM patients who experience severe hypos. Physicians should take steps to recognize and manage these conditions.

Incremental Burden on Quality of Life and Health Care Expenditures in Adults with Diabetes Complications: MEPS 2013–2015

Incremental Burden on Quality of Life and Health Care Expenditures in Adults with Diabetes Complications: MEPS 2013–2015

The quest to expand the coverage of public health insurance in the occupied Palestinian territory: an assessment of feasibility and sustainability using a simulation modelling framework

BackgroundIn their quest for universal health coverage (UHC), many developing countries explore alternative financing strategies to address the potential budgetary impact of health coverage expansion (for example, deferred debt versus current finance through taxation or premiums). Given the limited fiscal space, these policies may have different implications for fiscal sustainability and may worsen intergenerational inequality. MethodsWe assessed the impact of UHC on fiscal sustainability and intergenerational inequality using an overlapping generations model within a general equilibrium framework, which we calibrate using data from the Palestinian Expenditures and Consumption Survey (PECS-2011) and the Social Accounting Matrix (SAM-2011). Fiscal sustainability is assessed using a prudent debt–GDP level of 39%. Intergenerational inequality induced by different policies is assessed by comparing the relative incremental burden (RIB) borne by each generation following the policy adjustment. FindingsIn the absence of any policy adjustment, an ad hoc expansion of health coverage would increase the debt–GDP level to 15% above the prudent level. This indicates that the UHC fiscal stance may be financially unsustainable in the long run, therefore calling for a policy adjustment. Among the policies we examined, UHC finance through the increase of premiums (whether current or deferred) seems to be unsustainable and may further widen intergenerational inequality (RIB∈[3,6]). By contrast, current finance through indirect taxes helps to restore a prudent debt–GDP level and seems to be associated with a lower level of intergenerational inequality than deferred-debt finance through direct taxation (RIB of 1·25 and 5, respectively). InterpretationAmong the policy options assessed, the current indirect taxation emerged as the best policy option in terms of its impact on both fiscal sustainability and intergenerational inequalities. However, from a policy perspective, the capacity of governments to raise additional revenues might be constrained in the short-term. Under such circumstances, deferred-debt finance may be preferred—a situation in which policy makers may have to trade fiscal sustainability against intergenerational inequality. FundingThe A*MIDEX project (number ANR-11-IDEX-0001-02) funded by the French Government programme Investissements d'avenir, managed by the French National Research Agency (ANR).

THE IMPACT OF MITRAL REGURGITATION ON MORTALITY AND HEART FAILURE ADMISSIONS IN NEWLY DIAGNOSED HEART FAILURE PATIENTS

This analysis estimates the incremental burden of functional mitral regurgitation (FMR) in time to hospitalization or death for incident heart failure (HF) patients. Data from the Truven Health MarketScan between October 2011 and September 2016 was used. Patients with at least 1 inpatient or 2

The Cost of Hypoglycemia Associated With Type 2 Diabetes Mellitus in Taiwan

ObjectivesTo quantify the incremental burden of patients with type 2 diabetes mellitus (T2DM) and a hypoglycemic event in Taiwan using the National Health Insurance Research Database. MethodsData from 2000 through 2013 with an index period of 2001 through 2012 from the National Health Insurance Research Database’s 2-million-patient sample were used. Using a nested case-control study design, patients were indexed if they reported a diagnosis of T2DM during the index period. Patients with T2DM with a hypoglycemic event (defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes) during the index period were identified. Patients with T2DM without a hypoglycemic event were included to form a 4:1 (controls to cases) matched cohort on the basis of age, sex, the Charlson Comorbidity Index, and the T2DM diagnosis date. Both cohorts were followed up for 1 year after the hypoglycemic event and had their treatment utilization, resource utilization, and healthcare costs measured. ResultsA total of 144 213 patients with T2DM were identified, with 3 651 (2.5%) recording a hypoglycemic event. Before matching, patients with T2DM with a hypoglycemic event were, on average, older (64.2 vs 56.6) and had higher mean CCI scores (2.4 vs 1.9) than did patients with T2DM without a hypoglycemic event. After matching, patients with T2DM and a hypoglycemic event incurred an additional $1353 in average direct healthcare costs during the 1 year of follow-up compared with the matched cohort. Patients with T2DM with hypoglycemia also spent an additional 5.9 days in the hospital during the follow-up period compared with the matched cohort. ConclusionsPatients with hypoglycemic events, on average, experienced a substantially higher economic burden than did their counterparts without a hypoglycemic event during the same period.

The incremental economic burden of heart failure: A population-based investigation from South Korea.

BackgroundThe prevalence of heart failure (HF) and its economic burden are increasing with age of the South Korean population. This study aimed to assess the economic impact of HF from the societal perspective.MethodsA prevalence-based, incremental cost-of-patient study was performed to estimate the cost ratio between patients with HF and those without HF based on the claims database of the national health insurance in South Korea. We defined adult HF patients as those aged ≥19 years who had at least one insurance claim record with a primary or secondary diagnosis of HF. Age- and gender-matched controls were defined using a 1:4 greedy matching method. Costs were estimated by including medical costs for insurance-covered and non-covered services, transportation costs, caregiver’s cost, and time costs of patients. The ratio of costs between patients with HF and those without HF was adjusted for age, gender, and type of universal health security program in the multivariate regression model.ResultsThe average annual per-capita cost was estimated to be $6,601 for patients with HF (n = 14,252), which is about 3.38 (95% confidence interval [CI]: 3.31–3.46) times higher than that for patients without HF (n = 1,116,882) and 1.64 (95% CI: 1.59–1.70) times higher than that for the age- and gender-matched patients without HF (n = 57,008). In the multivariate regression model, the annual per-capita total costs were 1.98-fold (95% CI: 1.94–2.02) statistically higher for patients with HF than for patients without HF after adjustment for age, gender, and type of universal health security program.ConclusionsThis study demonstrates a significant incremental burden of HF. Given that the prevalence of HF is expected to increase with an increase in the aging population, the national economic burden is expected to be substantial in the future. Thus, greater emphasis on the prevention and treatment of HF is warranted.

Economic Burden of Venous Thromboembolism in Cancer Patients — a Comparative Analysis between Matched Patients with Cancer with and without a Diagnosis of Venous Thromboembolism

Background:Venous thromboembolism (VTE) is a major health problem occurring at a rate of 1/1000 adults in general population. Cancer patients have a much higher risk of VTE with an annual rate of 24.6/1000 patients and this contributes to significant morbidity and mortality in this patient population. The body of evidence related to the economic burden for VTE in cancer patients is limited to small institutional studies. With increasing burden of cost for cancer care there is a significant push for cost containment measures, physicians taking care of these patients should be more aware of the economic outcomes of their patient cares.Methods: We used a large claims based data set US database MarketScan (Truven Health Analytics) to explore the economic burden of VTE in cancer patients. Between January 1, 2013 and September 30, 2015 we identified 614,577 patients with cancer of these 195,290 were deemed to have active cancer out of which 6,569 had a VTE code in their medical claims. This study was conducted to assess the economic burden of VTE in cancer patients in comparison their non-VTE peers with similar cancer type.All-cause costs over 3-year period were used and included the costs of all services. These were further explored to compare the total cost of care, cost based on the site of utilization of care and pharmacy cost between the patients with VTE with their matched peers. VTE-related costs were identified with a primary or secondary diagnosis of DVT or PE, and were evaluated for the entire follow-up period, starting from the initiation of the anticoagulant therapy until end of eligibility or end of data, whichever was earlier. Continuous factors were summarized by the median. Wilcoxon signed-rank tests were used to test for differences in the distribution between the VTE and non-VTE groups for cost and number of visits. Overall costs as well as total cost per day/visit were compared between groups. The costs were also evaluated by site of utilization (Emergency room vs inpatient vs outpatient) and by cancer subtype.Results:Among active cancer enrollees, there were 6,569 (3.4%) enrollees with VTE and 188,721 (96.6%) without. Average age was around 60 years in both groups. There were approximately 50 % females in each group and breast cancer was the most common type of cancer in the non-VTE group while gastrointestinal cancers were more common in the VTE group. Incidence of comorbid conditions like diabetes, hypertension and chronic kidney disease was similar in both cohorts but chronic liver disease was found more often in the VTE cohort. The median total cost over the study period for the VTE group ($136,976) was 2.0 times that of the non-VTE group ($67,115). This pattern holds for the inpatient, emergency, and outpatient costs. Total median drug costs were about 4 times that of the VTE group ($10,457) than the non-VTE group ($2,621). The difference the cost between groups for these measures were all highly statistically significant (<0.001). However, the VTE group also had 1.7 times the median number of days/visits than the non-VTE group (p < 0.001 for all categories). After adjusting for the number of days, the median total cost per visit was still statistically significant (p<0.001); however the cost difference is much smaller ($1,132 in VTE vs. $984 in non-VTE,). The overall total cost in the VTE groups ranges from 1.3 (pancreatic) to 3.4 (other cancers) times that of the non-VTE patients for the various cancer types, all were statistically significant (p<0.001). After adjusting for the number of visits, the relative cost difference decreased for all cancer groups it ranges from 0.97 (gynecological) to 1.5 (other cancer) times that of the non-VTE patients for the various cancer groups. Lung, breast, gastrointestinal, and other types were statistically significant (p < 0.01).Discussion:Based on the real world information from a large insurance claims database, this study quantifies the incremental health care cost burden associated with VTE in cancer patients. It is clear from this study the patients with cancer and VTE seek medical care more frequently than their non-VTE counterparts leading to higher healthcare costs in all settings. It was also interesting to note that when only the drug costs were taken into consideration, enrollees with VTE had up to 4 times higher drug costs, not all of which was attributable to the anticoagulant cost. DisclosuresKhorana:Bayer: Consultancy; Sanofi: Consultancy; Pfizer: Consultancy; Janssen: Consultancy.

The Humanistic and Economic Burden Associated with Anxiety and Depression among Adults with Comorbid Diabetes and Hypertension.

We conducted a retrospective cross-sectional study to estimate the humanistic and economic burden associated with depression and anxiety among adults with comorbid diabetes and hypertension. Pooled data from the 2013 and 2015 Medical Expenditure Panel Survey were used to include adults (≥18 years old) who were alive and diagnosed with both diabetes and hypertension during the observation period. We assessed the humanistic burden with health-related quality of life (HRQoL) and economic burden with the total annual healthcare expenditures. Depending on the presence/absence of depression and anxiety, the study sample was divided into four groups (i.e., no depression/anxiety, depression only, anxiety only, and depression and anxiety). Multivariable regression analyses were used to evaluate the associations between the depression/anxiety categories and disease burden measures. The incremental burden associated with depression and/or anxiety was estimated with the counterfactual recycled prediction. Of the 4560 adults with comorbid diabetes and hypertension, 13.2% reported depression only, 8.7% reported anxiety only, and 7.7% reported both. Results from adjusted analyses indicated that the presence/absence of depression and anxiety was associated with significantly poorer HRQoL, especially on the mental component. Having either depression or anxiety corresponded to reduced mental component summary scores by more than four points. The reduction was as high as 10.35 points when both conditions occurred. Comparing to adults without depression or anxiety, the per-capital incremental annual healthcare expenditures were $4607 for the depression group, $2481 for the anxiety group, and $8709 for adults with both conditions. Furthermore, adults with depression and anxiety were 58% more likely to spend at least 10% of annual household income on healthcare as compared to those with neither the conditions. Our results highlight the needs for integrating cost-effective mental health services into diabetes management to improve the HRQoL and reduce healthcare costs for adults with comorbid diabetes and hypertension.